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Woman With Hypoxia and Long Bone Fractures
The Journal of Emergency Medicine, Vol. 44, No. 5, pp. e357–e358, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2012.07.087
Visual Diagnosis in Emergency Medicine WOMAN WITH HYPOXIA AND LONG BONE FRACTURES Shane Jenks, MD, Jennifer Carnell, MD, and Stanley Wu, MD Department of Internal Medicine, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas Reprint Address: Shane Jenks, MD, Department of Internal Medicine, Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Mail Stop BCM 285, Houston, TX 77030
Diagnosis
CASE REPORT
Fat emboli. In acute fracture, fat, bone, and bone marrow are showered from the fracture site together, giving off macro- and microemboli (2). Commonly associated with closed long bone or pelvic fractures, clinical signs of fat embolism include hypoxemia, respiratory insufficiency, petechial rash, and neurologic changes. The full clinical syndrome associated with fat embolism usually takes 24 to 72 h to develop (3). However, orthopedic studies demonstrate that intraoperative identification of emboli by ultrasound corresponds with real-time decreases in pulmonary artery oxygen saturation and pulmonary hypertension before other clinical signs appear (2,4). In addition, the relative quantity and size of ultrasound-identified fat emboli have been shown to correlate with clinical outcomes (2). Our bedside ultrasound examination allowed early identification of numerous fat emboli as the likely cause of our patient’s hypoxia in the setting of multiple comminuted pelvic and lower extremity fractures.
A 63-year-old woman arrived at the Emergency Department (ED) with obvious multiple fractures of the ribs, pelvis, and bilateral lower extremities after a highspeed motor-vehicle accident. She deteriorated acutely, becoming hypoxic and hypotensive. Chest x-ray findings were concerning for extremely small bilateral pneumothoraces. After bilateral chest tube placement and intubation, her hypoxia and hypotension continued on mechanical ventilation. Focused Assessment of Sonography in Trauma examination and diagnostic peritoneal lavage, both negative for intra-abdominal free fluid, and chest computed tomography (CT) scan failed to identify the cause of her instability. After the Rapid Ultrasound for Shock and Hypotension protocol for evaluation of her hypotension, Video 1 of the inferior vena cava was obtained, revealing a possible cause of her hypoxia (1).
REFERENCES Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1. No grants or other financial support have been received by the authors.
1. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin N Am 2010;28:29–56. 2. Pitto RP, Blunk J, Kobler M. Transesophageal echocardiography and clinical features of fat embolism during cemented hip arthroplasty. Arch Orthop Trauma Surg 2000;120:53–8.
RECEIVED: 27 January 2012; ACCEPTED: 4 July 2012 e357
e358
S. Jenks et al.
3. Georgopoulos D, Bouros D. Fat embolism syndrome: clinical examination is still the preferable diagnostic method. Chest 2003;123:982–3. 4. Pell AC, Christie J, Keating JF, et al. The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br 1993;75:921–5.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2012.07.087.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
http://dx.doi.org/10.1016/j.jemermed.2012.07.087
Visual Diagnosis in Emergency Medicine WOMAN WITH HYPOXIA AND LONG BONE FRACTURES Shane Jenks, MD, Jennifer Carnell, MD, and Stanley Wu, MD Department of Internal Medicine, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas Reprint Address: Shane Jenks, MD, Department of Internal Medicine, Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Mail Stop BCM 285, Houston, TX 77030
Diagnosis
CASE REPORT
Fat emboli. In acute fracture, fat, bone, and bone marrow are showered from the fracture site together, giving off macro- and microemboli (2). Commonly associated with closed long bone or pelvic fractures, clinical signs of fat embolism include hypoxemia, respiratory insufficiency, petechial rash, and neurologic changes. The full clinical syndrome associated with fat embolism usually takes 24 to 72 h to develop (3). However, orthopedic studies demonstrate that intraoperative identification of emboli by ultrasound corresponds with real-time decreases in pulmonary artery oxygen saturation and pulmonary hypertension before other clinical signs appear (2,4). In addition, the relative quantity and size of ultrasound-identified fat emboli have been shown to correlate with clinical outcomes (2). Our bedside ultrasound examination allowed early identification of numerous fat emboli as the likely cause of our patient’s hypoxia in the setting of multiple comminuted pelvic and lower extremity fractures.
A 63-year-old woman arrived at the Emergency Department (ED) with obvious multiple fractures of the ribs, pelvis, and bilateral lower extremities after a highspeed motor-vehicle accident. She deteriorated acutely, becoming hypoxic and hypotensive. Chest x-ray findings were concerning for extremely small bilateral pneumothoraces. After bilateral chest tube placement and intubation, her hypoxia and hypotension continued on mechanical ventilation. Focused Assessment of Sonography in Trauma examination and diagnostic peritoneal lavage, both negative for intra-abdominal free fluid, and chest computed tomography (CT) scan failed to identify the cause of her instability. After the Rapid Ultrasound for Shock and Hypotension protocol for evaluation of her hypotension, Video 1 of the inferior vena cava was obtained, revealing a possible cause of her hypoxia (1).
REFERENCES Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1. No grants or other financial support have been received by the authors.
1. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin N Am 2010;28:29–56. 2. Pitto RP, Blunk J, Kobler M. Transesophageal echocardiography and clinical features of fat embolism during cemented hip arthroplasty. Arch Orthop Trauma Surg 2000;120:53–8.
RECEIVED: 27 January 2012; ACCEPTED: 4 July 2012 e357
e358
S. Jenks et al.
3. Georgopoulos D, Bouros D. Fat embolism syndrome: clinical examination is still the preferable diagnostic method. Chest 2003;123:982–3. 4. Pell AC, Christie J, Keating JF, et al. The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br 1993;75:921–5.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2012.07.087.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.